America’s health care community awoke to a brave new world on November 9, 2016. Republicans will control Congress and the White House for the first time since 2006 —the first time since the passage of the Affordable Care Act (ACA) —and all signs suggest that they have big plans to shake up America’s health care system.
Despite a sparse health-related agenda, President Donald Trump’s platform did address the “need to reform our mental health programs and institutions in this country.” While alluding to the mental health provisions included in the 21st Century Cures Act signed into law by President Obama in December, the prioritization of mental health in the new President’s agenda gives the mental health community an opportunity to discuss policy changes with the Administration in 2017. Likewise, Republicans have openly discussed their desire to strengthen America’s mental health system as a response to the spate of gun massacres across the country. The enactment of the 21st Century Cures Act and the stated desire to further strengthen mental health supports suggest that mental health may continue to be a priority under Republican control.
That being said, a key priority for the new Congress and Administration—repealing the ACA—will have a significant impact on mental health coverage in this country. In addition, promises to increase military spending while cutting domestic social spending (including the Department of Health and Human Services) and efforts to reform and reduce funding for Medicaid will put mental health and substance use services out of reach for many Americans who need them most. In this article, we attempt to balance these issues and offer some perspective about the future of federal health care policy in 2017.
Repealing the ACA
The number of uninsured Americans has dropped significantly thanks to the ACA (aka ObamaCare), which gave states the ability to expand Medicaid coverage to everyone below a threshold of 138% of the federal poverty limit. In states that expanded Medicaid coverage, rates of uninsured adults have plummeted —and today nearly 95% of all children in this country are insured.
Medicaid is the single largest payer in the US for behavioral health services, including mental health and substance use services. All state Medicaid programs offer a behavioral health services package in a variety of settings, and all states cover prescription drugs. Children have an additional protection in the Early, Periodic, Screening, Diagnosis and Treatment benefit that guarantees coverage of all necessary health and behavioral health services to all children. What is more, the Mental Health Parity and Addiction Equity Act signed into law in 2008 and its subsequent expansion into Medicaid (including managed care) and the Children’s Health Insurance Program (CHIP) strengthen the entitlement to a comprehensive package of mental health services and treatments.
This comprehensive behavioral health benefit package removes a significant financial hurdle for Medicaid enrollees who access services. This is particularly true for low- income individuals for whom the cost of care represents a persistent and significant barrier to receiving needed behavioral health care services.
Repealing the ACA will seriously narrow the Medicaid program and could include restrictions on eligibility and limits on federal funding, turning back the significant progress that has been made. For example, policies could disallow states to expand their Medicaid program, require states to return to their pre-ACA eligibility levels, or limit federal funding for beneficiaries. These types of policies could force expansion states to eliminate coverage for millions of low-income beneficiaries or to finance coverage of the expansion populations entirely with state funds (a significant cost shift to state budgets).
Chris Koppen is President of Avancer Health Policy based in Alexandria, VA. Lena O’Rourke is President of O’Rourke Health Policy Strategies based in Arlington, VA. Both are experts in health care policy.
The authors report no conflicts of interest concerning the subject matter of this article.